Borderline personality disorder in suicidal adolescents.

Personality and Mental Health 7: 89–101 (2013) Published online 28 September 2012 in Wiley Online Library (wileyonlinelibrary.com) DOI 10.1002/pmh.1216

Borderline personality disorder in suicidal adolescents

SHIRLEY YEN, PHD1, KERRY GAGNON, BA2 AND ANTHONY SPIRITO, PHD1, 1Brown University, Department of Psychiatry and Human Behavior, Providence, RI, USA; 2University of Colorado Denver, Department of Psychology Denver, CO, USA ABSTRACT The diagnosis of borderline personality disorder (BPD) in adolescents has been controversial. Thus, few studies have examined BPD in suicidal adolescents, even though it is strongly associated with suicidal behaviours in adults. This study examines differences between suicidal adolescents with (n = 47) and without (n = 72) BPD on history and characteristics of suicidal behaviour, Axis I co-morbidity, affect regulation and aggression. Assessments were completed with both adolescents and parents, and consensus ratings based on best available data were analysed. BPD participants were more likely to have a history of suicide attempts and to have been admitted because of a suicide attempt (vs. suicidal ideation). There were no significant differences in self-injurious behaviours or degree of suicidal ideation. BPD participants also had more psychiatric co-morbidity and higher aggression scores but no significant differences in affective dysregulation compared with suicidal adolescents without BPD. Diagnostic stability over 6 months was modest. Our results demonstrate that, compared with other acutely suicidal adolescents, the clinical profile of BPD participants is unique and suggests an increased risk for suicidal behaviours. This extends upon other studies that support the construct validity of BPD during adolescence and suggests that BPD should be considered in suicide risk assessment for adolescents. Copyright © 2012 John Wiley & Sons, Ltd. Introduction There is ample evidence that borderline personality disorder (BPD) is strongly associated with suicidal and self-injurious behaviours, predicts significant functional impairment across a number of domains and is a costly disorder to treat (Bender et al., 2001; Skodol et al., 2005; Yen et al., 2003). Despite the severity of illness and functioning associated with this disorder in adults, relatively few studies have examined BPD in adolescents, and the application of this diagnosis to this age group remains controversial. This is particularly the case for studies of suicidal behaviours in adolescents. Large-scale epidemiological studies and treatment studies for

Copyright © 2012 John Wiley & Sons, Ltd.

adolescent suicidality typically do not assess for BPD, and BPD is often omitted from review studies of adolescent suicidality. The few studies that have examined BPD in suicidal adolescents found that attempters with a personality disorder are more likely to have made a previous attempt (Brent et al., 1993), display greater impulsivity and aggression and report more lifetime sexual abuse and stressful life events (Horesh, Nachshoni, Wolmer, & Toren, 2009; Horesh, Orbach, Gothelf, Efrati, & Apter, 2003) compared with counterparts with major depressive disorder (MDD). In a prospective follow-up study of suicidal adolescents, Greenfield et al. (2008) reported very high rates of BPD in those who made

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a suicide attempt during follow-up (90.9%). Other studies of BPD in adolescent inpatients (not necessarily restricted to those in acute suicidal crises) strongly suggest that those with BPD are more likely to have other diagnostic co-morbidities such as substance use disorder and conduct disorder (Grilo, Becker, Fehon, Edell, & McGlashan, 1996), bipolar disorder (Kutcher, Marton, & Korenblum, 1990), disruptive disorder (Rey, Morris-Yates, Singh, Andrews, & Stewart, 1995) and attention deficit hyperactivity disorder (Miller et al., 2008). Therefore, BPD in adolescents appears to be associated with increased risk for suicidality and greater psychopathology compared with other psychiatric disorders, which is likely to further exacerbate risk. In spite of these associated risks, there is a prominent reluctance to diagnosis of BPD during adolescence, and this issue remains controversial. Several factors contribute to this reluctance, including the developmental formation of personality, which continues throughout adolescence (Meijer, Goedhart, & Treffers, 1998); perceptions of personality disorders as chronic and intractable (Vito, Ladame, & Orlandini, 1999); stigma of personality disorders and well-intentioned efforts to not apply this label to the adolescent (Chanen et al., 2004); and the primacy of Axis I disorders in explaining psychiatric symptoms (Chanen, Jovev, & Jackson, 2007). Additional research, particularly within a subset of clinically severe suicidal patients, will further inform the debate on the concerns of premature diagnosis vs. underdiagnosis. In recent years, there has been increasing support for the construct of BPD in adolescents. Studies comparing adolescents with adults have reported that BPD features are comparable in frequency and in their manifestations of symptoms (Becker, Grilo, Edell, & McGlashan, 2002; Miller et al., 2008; Westen, Shedler, Durrett, Glass, & Martens, 2003). Furthermore, the internal consistency of BPD in adolescent samples is comparable with adult samples, and assessments of BPD in adolescents yield good convergent and concurrent validity (Bondurant, Greenfield, & Tse, 2004). However,


the diagnostic stability of BPD in adolescents appears to be lower than that of adults (Bondurant et al., 2004). Miller et al. (2008) identified a subgroup of adolescents with stable BPD diagnosis over time and a less severe subgroup that moved in and out of meeting full criterion. However, it should be noted that the diagnostic stability of BPD in adults has recently been called into question as well (Grilo et al., 2004; Shea et al., 2002; Zanarini, Frankenburg, Hennen, Reich, & Silk, 2005). Becker et al. (2002) report that the diagnostic efficiency of individual BPD criteria is lower for adolescent samples compared with that for adults. This may possibly be due to discontinuity across development during adolescence (Sharp & Romero, 2007). The cumulative evidence thus far seems to support the construct validity of BPD for adolescents, albeit yielding lower efficiency and stability compared with BPD in adults. The present study extends this body of research through a more specific examination of adolescent BPD in a particularly high-risk sample, i.e. adolescents admitted to an inpatient psychiatric unit for suicide risk. The present report represents a subset of findings from a prospective study that aims to identify prospective predictors of suicidal behaviours. In another set of findings, BPD was not found to be a significant predictor of prospective suicide events in multivariate analyses (Yen et al., 2012). However, 49% of those who met criteria for BPD (compared with 30% of those without BPD) reported a suicide event during follow-up. These figures, although lacking in statistical significance, are clinically significant and prompt further consideration of the relevance of BPD to understanding adolescent suicidality. To this end, we sought to first examine the prevalence of BPD in consecutively recruited suicide-related admissions to an adolescent psychiatric unit. We compared those with and without BPD on characteristics and history of suicidal behaviours, Axis I comorbidity, affect regulation and aggression to determine whether those with BPD have a unique clinical profile, distinct from those with other high-risk psychiatric morbidities. To extend upon

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Borderline personality disorder in adolescents

extant empirical research that supports the construct validity of BPD in adolescents, we examined the degree of association between BPD and constructs hypothesized to be associated with BPD, such as affect intensity, reactivity and aggression. Given the shift towards dimensional representation of personality disorders in DSM-V, BPD will be operationalized both categorically (on the basis of current DSM-IV criteria) (American Psychiatric Association, 2000) and dimensionally (on the basis of number of criteria endorsed). Finally, we examined the diagnostic stability of the BPD diagnosis over 6 months of prospective follow-up. Methods Participants Participants consisted of 119 adolescents, between the ages of 12–18 years (mean = 15.3, SD = 1.4) recruited from an adolescent inpatient psychiatric unit on the basis of having been recently admitted to the unit for elevated suicide risk (e.g. recent suicide attempt, self-injury with suicidal ideation, or suicidal ideation). Additional information was provided by their parents or legal guardians. In order to be eligible for inclusion, participants had to be fluent in English and to have been admitted because of suicide risk (e.g. a recent suicide attempt, suicidal ideation, plan or preparation for suicide). There were no diagnostic exclusion criteria other than evidence of an acute and primary psychotic disorder or cognitive impairment that would affect the reliability of interview and self-report data. Eligible consecutive recruitments from February 2006 to March 2010 were approached for parental consent and adolescent assent prior to the intake assessment. This study was approved by the relevant institutional review boards. Adolescents and parents were each compensated for their time with a payment of $50 for each the baseline interview and for the 6-month follow-up interview. Of the baseline sample of 119 participants, 81 (68%) were female, and 38 (32%) were male. The sample was 78.5% White, 10.0% African


American, 1.7% American Indian and 9.8% endorsing other or multiple races. Twenty-two (18%) participants reported Hispanic ethnicity. Thus, this sample was ethnically and racially diverse. Of the 119 participants who completed the baseline assessment, 104 provided some follow-up data, and 99 provided at least 6 months of follow-up data. The proportion of BPD diagnosis at baseline did not significantly differ between those who did and did not complete follow-up. Measures Schedule for Affective Disorders and Schizophrenia for School Aged Children—Present and Lifetime versions. The Schedule for Affective Disorders and Schizophrenia for School Aged Children— Present and Lifetime versions (K-SADS-PL) (Kaufman et al., 1997) was used to determine psychiatric diagnoses, current psychosocial functioning, treatment history, abuse history and family history of illness at baseline. The K-SADS is a semi-structured diagnostic interview that provides a reliable and valid assessment of DSM-IV psychopathology in children and adolescents. Interrater agreement has been found to be high by the developers (range: 93–100%) and in this current sample (kappa range 0.61–1.00 for disorders endorsed by at least 15% of the sample). Probes and objective criteria are provided to rate individual symptoms. The K-SADS-PL was administered with adolescent and caregiver participants individually. Consensus ratings were used to establish presence or absence of a diagnosis. The K-SADS-PL also includes a suicide module (Kaufman et al., 1997), a semi-structured assessment of severity of suicidal ideation, recurrent thoughts of death, seriousness of suicidal acts, medical lethality of suicide attempts and nonsuicidal physical self-damaging acts. Data on lifetime and present episodes of suicide attempts were assessed at baseline. Childhood Disorders.

Interview for Borderline Personality The Childhood Interview for Borderline

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Personality Disorders (CI-BPD) is the adolescent adaptation of the Diagnostic Interview for DSM-IV Personality Disorders (DIPD-IV) (Zanarini, Frankenburg, Sickel, & Young, 1996), a semistructured diagnostic interview consisting of questions that assess each criterion of the 10 DSM-IV personality disorders. The CI-BPD focuses only on BPD. Each criterion was assessed with multiple questions and coded as absent, subthreshold or present. The DIPD-IV compares favourably with other structured interviews for personality disorders, with excellent inter-rater reliability and test–retest reliability (kappa coefficients for BPD = 0.94 and 0.85 respectively) (Zanarini, Frankenburg, Chauncey, & Gunderson, 1987). The CI-BPD was recently evaluated in a sample of 190 adolescent inpatients and was demonstrated to have good internal consistency (Cronbach’s a = 0.80), interrater reliability (k = 0.89) and convergent and concurrent validity (Sharp, Ha, Michonski, Venta, & Carbone, 2012). The CI-BPD was administered at baseline and at the 6-month follow-up. In the present sample, Cronbach’s a for parent report was 0.71 and for child was 0.72, and k statistic for inter-rater reliability based on 20 cases was 0.82. Beck Scale for Suicide Ideation (Beck & Steer, 1991). The Beck Scale for Suicide Ideation (BSS) is a 21-item self-report instrument designed to detect and measure severity of suicidal ideation experienced over the last week in adults and adolescents. Participants respond to items using a three-point Likert scale. Excellent internal consistency and content/construct/concurrent validity for the BSS has been reported in adult inpatient and outpatient samples (a = 0.87–0.97) (Beck & Steer, 1991) and high internal consistency in adolescent inpatient samples (Kumar & Steer, 1995; Steer, Kumar, & Beck, 1993). In the present sample of adolescent inpatients, Cronbach’s a = 0.92. Suicide Ideation Questionnaire (Reynolds, 1988).The Suicide Ideation Questionnaire (SIQ) (Reynolds, 1988) is a 30-item self-report instrument designed to assess thoughts about suicide experienced by


adolescents during the prior month. Participants respond to items using a seven-point Likert-type scale ranging from 0 (I never had this thought) to 6 (almost every day). The scale was developed on the basis of field testing with over 2400 participants. Excellent internal consistency (a = 0.97) and construct validity for the SIQ has been reported (Reynolds, 1988). Internal consistency was also extremely high in the present sample (Cronbach’s a = 0.97). Functional Assessment of Self-Mutilation (LloydRichardson, Perrine, Dierker, & Kelley, 2007). The Functional Assessment of Self-Mutilation (FASM) is a self-report instrument that assesses whether an individual has engaged in intentional self-harm (cutting or burning of skin) in the past year. The FASM consists of two parts. The first is a checklist of self-injurious behaviours in which respondents report frequency and whether they received medical attention. The second part, to be completed only if self-mutilation is endorsed, consists of 22 statements that assess the function of their behaviour by rating a list of reasons for self-injury rated on a four-point Likert scale ranging from never to often. The FASM has been successfully administered to adolescent samples (Guertin, Lloyd-Richardson, Spirito, Donaldson, & Boergers, 2001; Lloyd-Richardson et al., 2007). In the present study, we utilize responses from the first part of the FASM to determine the presence of self-injurious behaviour. Because of the nature of our recruitment and the measure, behaviours such as cutting were referred to as self-injurious behaviours rather than non-suicidal self-injury (NSSI) to avoid inferences that these behaviours lack suicidal intent. Affect Intensity Measure (Larsen & Diener, 1987). The Affect Intensity Measure (AIM) is a 40-item self-report questionnaire with responses on a Likert scale. This measure assesses the typical strength of an individual’s affective responsiveness and is an important component to understanding emotion regulation processes. It contains three subscales: negative intensity, positive affectivity and negative

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reactivity; higher scores indicate higher intensity. Thus, the AIM captures affective functioning in both positive and negative valences and for both intensity and reactivity, two distinct components of affective regulation. Higher scores indicate greater intensity/reactivity. Because it consists of subscales of opposing valences, analyses of individual subscales are critical to understanding the affective profile. The AIM was administered to the adolescent participant at baseline. The AIM has strong test–retest reliabilities (0.81 for 3-month interval and 0.75 for 2-year interval) and adequate convergent and discriminant validity. In the present sample, Cronbach’s a = 0.86. Aggression Questionnaire (Buss & Perry, 1992). The Aggression Questionnaire (AQ) is a full revision of the Buss–Durkee Hostility Inventory, a widely used measure assessing hostility and aggression. Its 34 items are scored on the following five scales: Physical Aggression, Verbal Aggression, Anger, Hostility and Indirect Aggression. A total score is also provided, along with an Inconsistent Responding Index (a form of a lie scale). Standardization is based on a sample of 2138 individuals, aged 9 to 88 years, and norms are presented in three age sets: 9 to 18 years, 19 to 39 years, and 40 to 88 years. On the basis of the 9–18-year-old set where n = 1062, reliability and validity are both acceptable. The AQ was administered to both the adolescent and the parent. In this study, we will report parent data on aggression and behavioural dysregulation as these are observable, externalizing phenomena. Cronbach’s a for parent report was 0.95 and for child was 0.93. Emotion Regulation Checklist—Adapted (Shields & Cicchetti, 1997). The Emotion Regulation Checklist—Adapted (ERC) is a 24-item other report measure that can be completed in 10 min by adults familiar with the child. Raters are asked to judge on a four-point Likert scale ranging from 1 (almost always) to 4 (almost never) on how characteristic each item is for a particular child.


The ERC assesses for affective liability, negativity, reactivity and emotional intensity. The adapted version uses simple language, which was used in the National Study for Child Care in Low Income Families. In the present sample, Cronbach’s a = 0.76 for the overall scale. The Negative Affective Self-Statement Questionnaire (Ronan, Kendall, & Rowe, 1994). The Negative Affective Self-Statement Questionnaire (NASSQ) encompasses 39 self-statements associated with negative affect in children and adolescents (Ronan et al., 1994). It has been found to be internally reliable and temporally stable. Additional analyses supported concurrent and construct validity. A factor analysis of the items on the NASSQ suggests four factors: depressive self-statements, anxiety/somatic self-statements, negative affect self-statements and positive affect self-statements (Lerner et al., 1999). In the present sample, Cronbach’s a = 0.94 (anxiety), 0.83 (depression) and 0.88 (negative affectivity). Procedure All participants were administered baseline interviews and self-report instruments that assessed demographic information, diagnoses and functioning, history of suicidal and self-injurious behaviours and suicidal ideation, affective regulation and behavioural regulation. All interviewers were trained directly by the principal investigator, and all interviews were recorded for training and reliability purposes. The training process included: didactic training, reviewing and coding tapes of past interviews, observing interviews and finally conducting independent interviews. Interviews were regularly reviewed by the principal investigator. The majority of participant interviews (66%) were conducted by clinical psychology postdoctoral fellows, whereas 31 % were conducted by interviewers with a bachelor’s degree and 3% with a master’s degree. Whenever possible, assessments were administered to both adolescent and parent/ guardian; 87% of parents/guardians provided

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collateral data. When reports were discrepant, consensus scores were determined during weekly case review meetings using all available information, including chart review and information from the treating physician on the adolescent unit. Unless indicated by other information, our general protocol was to assign more weight to the adolescent report for internalizing symptoms and more weight to parent report for externalizing symptoms. Following the baseline assessments, patients were then contacted every 2 months over the subsequent 6 months (26 weeks). During this phone call, important life events were assessed to assist with recall at the full 6-month interview. Additionally, a brief assessment of the primary predictors and outcomes of interest to this study was reviewed. At the final 6-month follow-up assessment, a more comprehensive assessment of these variables, using measures reported in the following text, was administered.

Results At baseline, 40% of the sample met diagnostic criteria for BPD. The number of symptoms endorsed by participants was normally distributed with a mean number of 3.98 (SD = 2.23) criteria endorsed. The most frequently endorsed criteria were the following: self-injurious behaviours (91.7% in BPD group, 70.8% in NBPD group), impulsivity (85.4% in BPD group, 40.3% in NBPD group) and affective instability (85.4% in BPD group, 36.1% in NBPD group). Notable discrepancies between groups were observed for two criteria: relationship disturbance (66.7% in BPD group vs. 5.6% in NBPD group) and anger (89.6% in BPD group vs. 23.6% in NBPD group). An examination of the nine criteria BPD interview indicates it has adequate internal consistency (Cronbach’s a = 0.72). Demographic characteristics

Data analyses To determine the differences between participants meeting criteria for BPD (BPD group) and those who did not meet full threshold criteria for BPD (NBPD group) with regards to demographic characteristics, history of suicidal and self-injurious behaviours and characteristics, Axis I co-morbidity, and affective and behavioural dysregulation, t-tests were used for continuous outcomes, whereas chisquare analyses were used for categorical outcomes. To examine BPD dimensionally, operationalized as the number of BPD criteria endorsed, we conducted Pearson (for continuous correlates) and Spearman’s (for categorical correlates) correlations. We also conducted these same correlations excluding the self-injurious behaviours criterion and found no statistically significant differences from analyses using all nine criteria. Therefore, only the results from using the full nine criteria are presented. Kappa statistics were calculated to examine diagnostic stability from baseline to 6-month follow-up for child report and parent report.


Table 1 depicts demographic characteristics of the baseline sample by BPD status. There was no significant difference in mean age between BPD and NBPD (t = 0.989, p = 0.33). Approximately two-thirds of the baseline sample was female (67.2%), and among those with BPD, 81% were female (X2 = 6.54, p = 0.01). With regard to race, because of the large number of participants that reported multiple racial and ethnic categories, we analysed race and ethnicity in three ways by creating dichotomous groupings for the following: (1) White vs. non-White; (2) Hispanic vs. nonHispanic; (3) any minority vs. no minority status (i.e. non-Hispanic White). There were no statistically significant differences on age, ethnicity or race between BPD vs. NBPD groups. Baseline suicidal and self-injurious behaviours We compared history of suicidal and self-injurious behaviours in patients with BPD vs. those without BPD. Specifically, we examined the precipitating behaviour (e.g. attempts, ideation, threat or preparatory behaviour) that prompted the index hospital

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Table 1: Demographic and clinical characteristics by BPD status

Variable Demographic Gender, female (%) Race, White (%) Race, minority (%) Ethnicity (Hispanic or Latino) (%) SB characteristics SA at admittance (%) SI at admittance (%) Self-mutilation (%) History of SA Axis I disorders MDE Bipolar disorder Any disruptive disorder Any anxiety disorder Any substance disorder Any stress disorder Any eating disorder Sexual abuse history

Baseline

BPD

No-BPD

N = 119

N = 47

N = 72

Chisquare

80 (67.2) 97 (82.2) 30 (25.4) 21 (17.9)

38 (80.9) 36 (76.6) 12 (25.5) 7 (14.6)

42 (58.3) 61 (85.9) 18 (25.4) 14 (20)

6.544** 1.679 0.000 0.498

40 (33.6) 111 (93.3) 79 (76) 35 (50)

21 (44.7) 45 (95.7) 34 (82.9) 72 (62.1)

19 (26.4) 66 (91.7) 45 (71.4) 37 (80.4)

4.264* 0.754 1.798 10.921***

101 (84.9) 13 (10.9) 44 (37) 50 (42) 20 (16.8) 30 (25.2) 13 (10.9) 29 (29)

45 (95.7) 9 (19.1) 23 (48.9) 19 (40.4) 10 (21.3) 18 (38.3) 8 (17) 14 (33.3)

56 (77.8) 4 (5.6) 21 (29.2) 31 (43.1) 10 (13.9) 12 (16.7) 5 (6.9) 15 (25.9)

7.150** 5.4* 4.769* 0.081 1.110 7.057** 2.967 0.660

SB, suicidal behaviour, SA, suicide attempt; SI, suicidal ideation; MDE, major depressive episode. *p < 0.05. **p < 0.01. ***p < 0.001.

admission, suicide attempt history, intent and medical threat of past attempts, self-injurious behaviours and suicidal ideation in the week prior and month prior to index admission. The BPD group had a higher rate of attempts precipitating admission (45% vs. 26%; X2 = 4.26, p = 0.04) and were significantly more likely to have a history of suicidal attempts (81% vs. 50%; X2 = 10.92, p = 0.001). There were no significant differences in levels of intent or medical lethality in the suicide attempts reported by BPD vs. NBPD groups. Furthermore, there were no significant differences in the prevalence of self-injurious behaviours (83% of BPD and 71% of NBPD), frequency of self-injurious behaviours or in the proportion seeking medical treatment for self-injurious behaviours. Furthermore, there was no significant difference between BPD and NBPD groups on level of suicidal ideation (Table 1).


Analyses of BPD operationalized dimensionally revealed statistically significant correlations between number of BPD criteria endorsed and suicide attempt precipitating admission (r = 0.22, p = 0.018), history of suicide attempts (r = 0.26, p = 0.005), suicidal ideation in the week prior to intake assessed by the BSS (r = 0.30; p = 0.003) and suicidal ideation in the month prior to intake assessed by the SIQ (r = 0.26; p = 0.008). Psychiatric disorders Table 1 depicts results from the chi-square analyses that examine differences between BPD and NBPD participants with regard to prevalence of co-morbid Axis I disorders at baseline. Only rates of MDD, any disruptive disorders, and any stress disorder (post-traumatic stress disorder (PTSD), acute stress

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disorder) were significantly different for BPD and NBPD groups. Those with BPD had a mean Global Assessment of Functioning (GAF) score of 40.8 (SD = 6.8), whereas those who did not meet criteria for BPD had a mean GAF score of 44.3 (SD = 7.7); this difference was statistically significant (t = 2.52, p = 0.013). Our results using dimensional BPD yielded similar findings (MDD: r = 0.22, p = 0.015; disruptive disorders: r = 0.25, p = 0.007; stress disorders: r = 0.27, p = 0.003) and revealed new significant associations with bipolar disorder (r = 0.26, p = 0.004) and eating disorders (r = 0.22; p = 0.02). We examined the correlations between dimensional BPD and the GAF score at baseline and found the expected significant inverse correlation (r = 0.293, p = 0.001). Our significant findings with regard to differences in rates of co-morbid stress disorders prompted further analyses on whether those with and without BPD differed in abuse histories. There was no statistically significant difference between groups with regard to physical and sexual abuse history. Physical abuse was reported by 14% of those with and without BPD, and sexual abuse was reported by 33% in the BPD group compared with 26% in those without BPD. Behavioural dysregulation The AQ was administered to both the adolescent participant and their parent at baseline, and findings were similar on the basis of both reports. We report results from the parent report, as aggression and behavioural dysregulation are externalizing and observable phenomena. The total score, consisting of five subscales, was significantly associated with BPD (t = 2.21, p = 0.030). Examination of the parent report showed that three of the five subscales in particular accounted for the significance: anger (t = 2.30, p = 0.024), hostility (t = 2.18, p = 0.032) and indirect aggression (t = 2.02, p = 0.046). Correlations between number of BPD criteria and both the AQ as reported by the adolescent


(r = 0.40; p < 0.001) and the parent (r = 0.27; p = 0.009) were highly significant. There were significant correlations between each of the subscales of the AQ and number of BPD criteria endorsed. Affect dysregulation The overall baseline scores for the AIM and individual subscales of the AIM (i.e. negative intensity, positive affectivity, negative reactivity) were not significantly different between participants with and without BPD. This remained the case for correlation analyses between number of BPD symptoms and each of the AIM subscales. Analyses of the ERC found that of the two factors, only Negative Lability was significantly different between groups (t = 2.54, p = 0.013). Again, consistent with the correlation analyses, number of BPD symptoms was only significantly correlated with the Negative Lability subscale (r = 0.34, p = 0.001). The Emotion Regulation subscale was not significantly associated with BPD, operationalized dichotomously or categorically. With regard to the NASSQ, only the anxiety subscale significantly differed between groups, with the BPD sample reporting higher scores (t = 2.18, p = 0.03). This was validated by significant correlations between number of BPD symptoms and the anxiety subscale of the NASSQ (r = 0.33; p = 0.001). Furthermore, correlational analyses revealed additional significant correlations between BPD and the depression subscale (r = 0.29; p = 0.003) and the negative affect subscale (r = 0.25, p = 0.009). Therefore, when examined dimensionally, BPD was significantly associated with every subscale of the NASSQ. Diagnostic stability Table 2 depicts Cohen’s kappa statistics for concordance of ratings from baseline to the 6-month follow-up for child and parent report respectively. At the diagnostic level, concordance was fair on the basis of child report and moderate for parent

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Table 2: Cohen’s kappa statistics for baseline and 6-month ratings

Anger Affect instability Emptiness Identity disturbance Dissociation Abandonment SIB Impulsivity Relationship disturbance BPD diagnosis

Child score

Parent score

0.31 0.48 0.38 0.51 0.25 0.46 0.13 0.30 0.45 0.25

0.37 0.40 0.34 0.32 0.41 0.50 0.11 0.60 0.53 0.42

SIB, self-injurious behaviour; BPD, borderline personality disorder.

report. At the criterion level, there was notably poor agreement on the self-injurious behaviours criterion for both child and parent. Concordance on remaining criteria ranged from fair (k = 0.25) to moderate (k = 0.60). Discussion In this report, we sought to examine the prevalence of BPD in consecutively recruited suicide-related admissions to an adolescent psychiatric unit and to examine the incremental risk associated with BPD in this acutely suicidal sample. We compared suicidal adolescent inpatients with and without BPD on characteristics and history of suicidal behaviours, Axis I co-morbidity, affect regulation and aggression to determine whether those with BPD exhibit differences distinct from those with other high-risk psychiatric morbidities in suicidal crises. Finally, we sought to add to the growing body of empirical studies that have examined the construct validity of BPD in adolescents by examining the degree of association between BPD and constructs hypothesized to be associated with BPD, such as affect intensity, reactivity and aggression. In summary, we found that BPD is prevalent among suicidal adolescents; that even in an acute clinical setting, suicidal patients with BPD have


more serious suicidal behaviour and have expected associations with hypothesized constructs. Thus, our findings offer strong support for the assessment of BPD in adolescents at high risk for suicidal behaviour and towards support for the construct validity of BPD in adolescents. Our sampling approach was transdiagnostic, with minimal diagnostic exclusions. Yet, BPD was the most prevalent psychiatric disorder (aside from MDD) in adolescents admitted to an inpatient psychiatric unit because of suicide risk. Furthermore, those with BPD are more likely to have made a suicide attempt that precipitated the index hospitalization and are more likely than those who do not have BPD to have a history of suicide attempts. Their attempts are just as serious with regard to intent to die and medical threat, countering a common misperception that the suicide attempts of BPD patients are manipulative or attention-seeking in nature and, thus, less serious. In addition, those who endorsed more BPD criteria tended to have higher levels of suicidal ideation in the week prior and month prior to their hospitalization. Thus, even compared with a cohort of acutely suicidal adolescents, those with BPD experienced more frequent and severe suicidal thoughts and were more likely to act upon their suicidal thought. Surprisingly, the rate of endorsement of selfinjurious behaviours (i.e. deliberate tissue damage regardless of suicidal intent) did not differ between BPD and NBPD groups. As this is a criterion of BPD, we expected higher rates among those meeting criteria for BPD. However, we note that a higher percentage of BPD patients responded affirmatively to the interview questions assessing self-injurious behaviours than those who endorsed self-injurious behaviours in the self-report questionnaire. This discrepancy may be because the DSM criterion of self-injury includes threats of self-harm in addition to behaviours. There is a growing body of literature that suggests that NSSI behaviours, such as cutting, extend well beyond the BPD diagnoses (Andover, Pepper, Ryabchenko, Orrico, & Gibb, 2005; Nock, Joiner, Gordon, Lloyd-Richardson, & Prinstein, 2006). Our findings

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indicate that self-injurious behaviours, such as cutting, are highly prevalent among suicidal adolescents regardless of diagnoses and less specific to BPD than originally conceptualized. Several patterns emerged in our BPD sample that are consistent with those observed in adults with BPD. The high proportion of girls diagnosed with BPD in the current sample (81%) is comparable with the estimate that 75% of BPD adults are women (APA, 2000). Similar to studies of adults, there were no other demographic differences between those with and without BPD. In our sample of adolescents, the highest diagnostic co-morbidities were observed with MDD and PTSD, which is also consistent with studies of BPD adults (Shea et al., 2004). Disruptive disorders were also frequently observed in our sample, consistent with recent studies that have found that attention deficit hyperactivity disorder and oppositional defiant disorder, particularly the oppositional behaviour dimension, were particularly predictive of BPD in adolescence (Burke & Strepp, 2012; Speranza et al., 2011). Disruptive disorders are exclusively diagnosed in adolescents but may foreshadow other externalizing disorders that are more likely to develop during adulthood such as substance use disorders. The construct that differed most substantially between those with and without BPD was aggression. Specifically BPD adolescents were rated by their parents as having more anger, hostility and indirect aggression, traits that are consistent with the BPD construct. Furthermore, excluding the self-injurious behaviour criterion, impulsivity was the BPD criterion most frequently endorsed by those who met criteria for BPD. A major limitation of the present study is the lack of a more thorough assessment for impulsivity, particularly as impulsivity is a multi-faceted construct in which different facets of impulsivity appear to be associated with varying degrees of risk for suicidal behaviours (Yen et al., 2009). Nonetheless, the observed differences in aggression may account for the higher risk for suicide attempts associated with BPD (as indicated by higher rates of past attempts and


greater likelihood of a suicide attempt precipitating index hospitalization). Our results in conjunction with studies showing that the neurobiological maturation of brain regions associated with impulse control are still in development during adolescence (Steinberg, 2007) suggests that impulsivity is particularly important to consider in adolescents. We expected differences on affective regulation traits between BPD and NBPD adolescents yet found few, particularly when BPD diagnosis was examined dichotomously. In the dimensional analyses, we found that those with more BPD criteria had higher levels of negative affectivity, depression and anxiety as assessed by the NASSQ and higher affective lability as assessed by the ERC. Notably, subscales of reactivity from the AIM or the ERC were not significantly different. Taken together, this suggests that the negative affective experiences of those with BPD are either more intense or reported at higher levels compared with those without BPD. Yet, suicidal adolescents with and without BPD endorse comparable levels of reactivity to their negative mood states. This suggests that affective dysregulation may be more transdiagnostic and not specific to BPD, particularly in a high-risk sample such as suicidal adolescents. It is also possible that affective dysregulation is widely experienced among suicidal adolescents (Chapman, Gratz, & Brown, 2006; Esposito, Spirito, Boergers, & Donaldson, 2003), resulting in a limited range of variance that precludes differentiation between BPD and NBPD groups. The baseline to 6-month diagnostic stability of BPD in our sample was modest, and less stable than observed in adults (Shea et al., 2002). In light of this, the modest concordance based on scores from two separate assessment intervals is not surprising. As mentioned previously, recent studies have also called into question the presumed chronicity and stability of personality disorders in adults (Grilo et al., 2004; Shea et al., 2002; Zanarini et al., 2005). Thus, again, our findings can be seen as broadly comparable with those observed in adults. However, there are several methodological limitations that complicate the interpretability of these

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findings. Most of our data are based on retrospective recall, which can be biased after a significant event, such as a suicide attempt or hospitalization. As all participants for the study were recruited as inpatients, when they were acutely suicidal, their responses are likely to be subject to strong state effects associated with their current hospitalization and recent suicidal crisis and thus not reflective of their typical functioning. Thus, our data are particularly vulnerable to state effects. Another limitation stemming from our recruitment site is that our sample was relatively homogeneous. Not only does this limit generalizability, but it also limits variability in the range of our data and, hence, our power to find statistically significant effects. However, the use of a stringent comparison group also adds strength to the significant findings that were identified as they cannot be accounted for by clinical factors such as depression and suicidality. In summary, BPD is prevalent among a high-risk group of suicidal adolescents. Those with BPD are distinguished from other suicidal adolescents on a number of clinical characteristics including a greater likelihood of having made a recent attempt and more likely to have a past suicide attempt, more Axis I diagnostic co-morbidities and higher levels of aggression. These differences are consistent with observed differences in adults with BPD and lend further evidence to the construct validity of BPD in adolescents. However, the stability of BPD in adolescents, on the basis of our study and those of other research groups, remains questionable. Nonetheless, the associated risks, particularly with regard to risks for suicidal behaviour, seem to warrant earlier identification so that patients can seek the most appropriate intervention at a very critical developmental juncture. Acknowledgements This work was supported by grant no. R34 MH06990 from the National Institute of Mental Health, Bethesda, Maryland to Dr. Yen. We are grateful for the support of our clinical collaborators including Dawn Picotte, M.D., Joel Solomon, M.D.,


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Address Correspondence to: Shirley Yen, PhD, Brown University, Providence, Rhode Island, United States. E-mail: Shirley_Yen_PhD@brown. edu

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Functions of non-suicidal self-injury in adolescents and young adults with Borderline Personality Disorder symptoms.

Impulsivity in borderline personality disorder.

Borderline personality disorder in adolescence.

Borderline personality disorder and mood.

INTEGRATIVE BORDERLINE ADOLESCENT FAMILY THERAPY: MEETING THE CHALLENGES OF TREATING ADOLESCENTS WITH BORDERLINE PERSONALITY DISORDER.

Time Left for Intervention in the Suicidal Process in Borderline Personality Disorder.

Psychotherapy for borderline personality disorder.

Borderline personality disorder and mood.

Epidemiology of borderline personality disorder.

Impairments in Object Relations and Chronicity of Suicidal Behavior in Individuals With Borderline Personality Disorder.

Self-harm and suicidal behavior in borderline personality disorder with and without bulimia nervosa.

Discrete subgroups of adolescents diagnosed with borderline personality disorder: a latent class analysis of personality features.

Prescribing and borderline personality disorder.

Preserved Error-Monitoring in Borderline Personality Disorder Patients with and without Non-Suicidal Self-Injury Behaviors.

Coping strategies associated with suicidal behaviour in adolescent inpatients with borderline personality disorder.

Sleep-Wake Patterns of Adolescents with Borderline Personality Disorder and Bipolar Disorder.

Effects of serotonin-2A receptor binding and gender on personality traits and suicidal behavior in borderline personality disorder.

Increased serum prolactin in borderline personality disorder.

Pain in patients with borderline personality disorder.

Emotions and memory in borderline personality disorder.

Dissociation in schizophrenia and borderline personality disorder.

Social judgement in borderline personality disorder.

Patient-reported outcomes in borderline personality disorder.

Correlates, stability and predictors of borderline personality disorder among previously suicidal youth.